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Critical thinking in healthcare and education

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• Peer review
• Jonathan M Sharples , professor 1 ,
• Andrew D Oxman , research director 2 ,
• Kamal R Mahtani , clinical lecturer 3 ,
• Iain Chalmers , coordinator 4 ,
• Sandy Oliver , professor 1 ,
• Kevan Collins , chief executive 5 ,
• Astrid Austvoll-Dahlgren , senior researcher 2 ,
• Tammy Hoffmann , professor 6
• 1 EPPI-Centre, UCL Department of Social Science, London, UK
• 2 Global Health Unit, Norwegian Institute of Public Health, Oslo, Norway
• 3 Centre for Evidence-Based Medicine, Oxford University, Oxford, UK
• 4 James Lind Initiative, Oxford, UK
• 5 Education Endowment Foundation, London, UK
• 6 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Australia
• Correspondence to: J M Sharples Jonathan.Sharples{at}eefoundation.org.uk

Critical thinking is just one skill crucial to evidence based practice in healthcare and education, write Jonathan Sharples and colleagues , who see exciting opportunities for cross sector collaboration

Imagine you are a primary care doctor. A patient comes into your office with acute, atypical chest pain. Immediately you consider the patient’s sex and age, and you begin to think about what questions to ask and what diagnoses and diagnostic tests to consider. You will also need to think about what treatments to consider and how to communicate with the patient and potentially with the patient’s family and other healthcare providers. Some of what you do will be done reflexively, with little explicit thought, but caring for most patients also requires you to think critically about what you are going to do.

Critical thinking, the ability to think clearly and rationally about what to do or what to believe, is essential for the practice of medicine. Few doctors are likely to argue with this. Yet, until recently, the UK regulator the General Medical Council and similar bodies in North America did not mention “critical thinking” anywhere in their standards for licensing and accreditation, 1 and critical thinking is not explicitly taught or assessed in most education programmes for health professionals. 2

Moreover, although more than 2800 articles indexed by PubMed have “critical thinking” in the title or abstract, most are about nursing. We argue that it is important for clinicians and patients to learn to think critically and that the teaching and learning of these skills should be considered explicitly. Given the shared interest in critical thinking with broader education, we also highlight why healthcare and education professionals and researchers need to work together to enable people to think critically about the health choices they make throughout life.

Essential skills for doctors and patients

Critical thinking is not a new concept in education: at the beginning of the last century the US educational reformer John Dewey identified the need to help students “to think well.” 3 Critical thinking encompasses a broad set of skills and dispositions, including cognitive skills (such as analysis, inference, and self regulation); approaches to specific questions or problems (orderliness, diligence, and reasonableness); and approaches to life in general (inquisitiveness, concern with being well informed, and open mindedness). 4

An increasing body of evidence highlights that developing critical thinking skills can benefit academic outcomes as well as wider reasoning and problem solving capabilities. 5 For example, the Thinking, Doing, Talking Science programme trains teachers in a repertoire of strategies that encourage pupils to use critical thinking skills in primary school science lessons. An independently conducted randomised trial of this approach found that it had a positive impact on pupils’ science attainment, with signs that it was particularly beneficial for pupils from poorer families. 6

In medicine, increasing attention has been paid to “critical appraisal” in the past 40 years. Critical appraisal is a subset of critical thinking that focuses on how to use research evidence to inform health decisions. 7 8 9 The need for critical appraisal in medicine was recognised at least 75 years ago, 10 and critical appraisal has been recognised for some decades as an essential competency for healthcare professionals. 11 The General Medical Council’s Good Medical Practice guidance includes the need for doctors to be able to “provide effective treatments based on the best available evidence.” 12

If patients and the public are to make well informed health choices, they must also be able to assess the reliability of health claims and information. This is something that most people struggle to do, and it is becoming increasingly important because patients are taking on a bigger role in managing their health and making healthcare decisions, 13 while needing to cope with more and more health information, much of which is not reliable. 14 15 16 17

Teaching critical thinking

Although critical thinking skills are given limited explicit attention in standards for medical education, they are included as a key competency in most frameworks for national curriculums for primary and secondary schools in many countries. 18 Nonetheless, much health and science education, and education generally, still tends towards rote learning rather than the promotion of critical thinking. 19 20 This matters because the ability to think critically is an essential life skill relevant to decision making in many circumstances. The capacity to think critically is, like a lot of learning, developed in school and the home: parental influence creates advantage for pupils who live in homes where they are encouraged to think and talk about what they are doing. This, importantly, goes beyond simply completing tasks to creating deeper understanding of learning processes. As such, the “critical thinking gap” between children from disadvantaged communities and their more advantaged peers requires attention as early as possible.

Although it is possible to teach critical thinking to adults, it is likely to be more productive if the grounds for this have been laid down in an educational environment early in life, starting in primary school. Erroneous beliefs, attitudes, and behaviours developed during childhood may be difficult to change later. 21 22 This also applies to medical education and to health professionals. It becomes increasingly difficult to teach these skills without a foundation to build on and adequate time to learn them.

Strategies for teaching students to think critically have been evaluated in health and medical education; in science, technology, engineering, and maths; and in other subjects. 23 These studies suggest that critical thinking skills can be taught and that in the absence of explicit teaching of critical thinking, important deficiencies emerge in the abilities of students to make sound judgments. In healthcare studies, many medical students score poorly on tests that measure the ability to think critically , and the ability to think critically is correlated with academic success. 24 25

Evaluations of strategies for teaching critical thinking in medicine have focused primarily on critical appraisal skills as part of evidence based healthcare. An overview of systematic reviews of these studies suggests that improving evidence based healthcare competencies is likely to require multifaceted, clinically integrated approaches that include assessment. 26

Cross sector collaboration

Informed Health Choices, an international project aiming to improve decision making, shows the opportunities and benefits of cross sector collaboration between education and health. 27 This project has brought together people working in education and healthcare to develop a curriculum and learning resources for critical thinking about any action that is claimed to improve health. It aims to develop, identify, and promote the use of effective learning resources, beginning at primary school, to help people to make well informed choices as patients and health professionals, and well informed decisions as citizens and policy makers.

The project has drawn on several approaches used in education, including the development of a “spiral curriculum,” measurement tools, and the design of learning resources. A spiral curriculum begins with determining what people should know and be able to do, and outlines where they should begin and how they should progress to reach these goals. The basic ideas are revisited repeatedly, building on them until the student has grasped a deep understanding of the concepts. 28 29 The project has also drawn on educational research and methods to develop reliable and valid tools for measuring the extent to which those goals have been achieved. 30 31 32 The development of learning resources to teach these skills has been informed by educational research, including educational psychology, motivational psychology, and research and methods for developing learning games. 33 34 35 It has also built on the traditions of clinical epidemiology and evidence based medicine to identify the key concepts required to assess health claims. 29

It is difficult to teach critical thinking abstractly, so focusing on health may have advantages beyond the public health benefits of increasing health literacy. 36 Nearly everyone is interested in health, including children, making it easy to engage learners. It is also immediately relevant to students. As reported by one 10 year old in a school that piloted primary school resources, this is about “things we might actually use instead of things we might use when we are all grown up and by then we’ll forget.” Although the current evaluation of the project is focusing on outcomes relating to appraisal of treatment claims, if the intervention shows promise the next step could be to explore how these skills translate to wider educational contexts and outcomes.

Beyond critical thinking

Exciting opportunities for cross sector collaboration are emerging between healthcare and education. Although critical thinking is a useful example of this, other themes cross the education and healthcare domains, including nutrition, exercise, educational neuroscience, learning disabilities and special education needs, and mental health.

In addition to shared topics, several common methodological and conceptual issues also provide opportunities for sharing ideas and innovations and learning from mistakes and successes. For example, the Education Endowment Foundation is the UK government’s What Works Centre for education, aiming to improve evidence based decision making. Discussions hosted by the foundation are exploring how methods to develop guidelines in healthcare can be adapted and applied in education and other sectors.

Similarly, the foundation’s universal use of independent evaluation for teaching and learning interventions is an approach that should be explored, adapted, and applied in healthcare. Since the development and evaluation of educational interventions are separated, evaluators have no vested interested in the results of the assessment, all results are published, and bias and spin in how results are analysed and presented are reduced. By contrast, industry sponsorship of drug and device studies consistently produces results that favour the manufacturer. 37

Another example of joint working between educators and health is the Best Evidence Medical Education Collaboration, an international collaboration focused on improving education of health professionals. 38 And in the UK, the Centre for Evidence Based Medicine coordinates Evidence in School Teaching (Einstein), a project that supports introducing evidence based medicine as part of wider science activities in schools. 39 It aims to engage students, teachers, and the public in evidence based medicine and develop critical thinking to assess health claims and make better choices.

Collaboration has also been important in the development of the Critical Thinking and Appraisal Resource Library (CARL), 40 a set of resources designed to help people understand fair comparisons of treatments. An important aim of CARL is to promote evaluation of these critical thinking resources and interventions, some of which are currently under way at the Education Endowment Foundation. On 22 May 2017, the foundation is also cohosting an event with the Royal College of Paediatrics and Child Health that will focus on their shared interest in critical thinking and appraisal skills.

Education and healthcare have overlapping interests. Doctors, teachers, researchers, patients, learners, and the public can all benefit from working together to help people to think critically about the choices they make. Events such as the global evidence summit in September 2017 ( https://globalevidencesummit.org ) can help bring people together and build on current international experience.

Contributors and sources: This article reflects conclusions from discussions during 2016 among education and health service researchers exploring opportunities for cross sector collaboration and learning. This group includes people with a longstanding interest in evidence informed policy and practice, with expertise in evaluation design, reviewing methodology, knowledge mobilisation, and critical thinking and appraisal.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

Provenance and peer review: Not commissioned; externally peer reviewed.

• ↵ Krupat E, Sprague JM, Wolpaw D, Haidet P, Hatem D, O’Brien B. Thinking critically about critical thinking: ability, disposition or both? Med Educ 2011 ; 357 : 625 - 35 . doi:10.1111/j.1365-2923.2010.03910.x   pmid:21564200 . OpenUrl
• ↵ Huang GC, Newman LR, Schwartzstein RM. Critical thinking in health professions education: summary and consensus statements of the millennium conference 2011. Teach Learn Med 2014 ; 357 : 95 - 102 . doi:10.1080/10401334.2013.857335   pmid:24405353 . OpenUrl
• ↵ Dewey J. How we think. D C Heath, 1910 . https://archive.org/details/howwethink000838mbp doi:10.1037/10903-000 .
• ↵ Facione PA. Critical thinking: a statement of expert consensus for purposes of educational assessment and instruction. Research findings and recommendations. American Philosophical Association, 1990 , http://files.eric.ed.gov/fulltext/ED315423.pdf .
• ↵ Higgins S, Katsipataki M, Coleman R, et al. The Sutton Trust-Education Endowment Foundation Teaching and Learning Toolkit. Education Endowment Foundation, 2015 .
• ↵ Hanley P, Slavin RE, Elliot L. Thinking, doing, talking science. Evaluation report and executive summary. Education Endowment Foundation, 2015 , https://v1.educationendowmentfoundation.org.uk/uploads/pdf/Oxford_Science.pdf .
• ↵ Sackett DL. How to read clinical journals: I. why to read them and how to start reading them critically . Can Med Assoc J 1981 ; 357 : 555 - 8 . pmid:7471000 . OpenUrl
• ↵ Guyatt G, Cairns J, Churchill D, et al. Evidence-Based Medicine Working Group. Evidence-based medicine. A new approach to teaching the practice of medicine . JAMA 1992 ; 357 : 2420 - 5 . doi:10.1001/jama.1992.03490170092032   pmid:1404801 . OpenUrl
• ↵ Oxman AD, Sackett DL, Guyatt GH. The Evidence-Based Medicine Working Group. Users’ guides to the medical literature. I. How to get started . JAMA 1993 ; 357 : 2093 - 5 . doi:10.1001/jama.1993.03510170083036   pmid:8411577 . OpenUrl
• ↵ Rynearson EH. Endocrinology: a critical appraisal . Cal West Med 1940 ; 357 : 257 - 9 . pmid:18745588 . OpenUrl
• ↵ General Medical Council. Tomorrow's doctors. General Medical Council, 1993. http://www.gmc-uk.org/10a_annex_a.pdf_25398162.pdf
• ↵ General Medical Council. Good medical practice. General Medical Council, 2013. http://www.gmc-uk.org/static/documents/content/GMP_.pdf
• ↵ Edwards A, Elwyn G. Shared decision-making in health care: achieving evidence-based patient choice. 2nd ed . Oxford University Press, 2009 .
• ↵ Sumner P, Vivian-Griffiths S, Boivin J, et al. Exaggerations and caveats in press releases and health-related science news. PLoS One 2016 ; 357 : e0168217 . doi:10.1371/journal.pone.0168217   pmid:27978540 . OpenUrl
• ↵ Schwartz LM, Woloshin S, Andrews A, Stukel TA. Influence of medical journal press releases on the quality of associated newspaper coverage: retrospective cohort study. BMJ 2012 ; 357 : d8164 . doi:10.1136/bmj.d8164 .  pmid:22286507 . OpenUrl
• ↵ Glenton C, Paulsen EJ, Oxman AD. Portals to Wonderland: health portals lead to confusing information about the effects of health care. BMC Med Inform Decis Mak 2005 ; 357 : 7 . doi:10.1186/1472-6947-5-7   pmid:15769291 . OpenUrl
• ↵ Moynihan R, Bero L, Ross-Degnan D, et al. Coverage by the news media of the benefits and risks of medications . N Engl J Med 2000 ; 357 : 1645 - 50 . doi:10.1056/NEJM200006013422206   pmid:10833211 . OpenUrl
• ↵ Voogt J, Roblin NP. A comparative analysis of international frameworks for 21st century competences: implications for national curriculum policies. J Curric Stud 2012 ; 357 : 299 - 321 doi:10.1080/00220272.2012.668938 . OpenUrl
• ↵  National Research Council. Taking science to school: learning and teaching science in grades K-8. National Academies Press, 2007 .
• ↵ Nordheim L, Pettersen KS, Flottorp S, Hjälmhult E. Critical appraisal of health claims: science teachers’ perceptions and practices . Health Educ J 2016 ; 357 : 449 - 66 doi:10.1108/HE-04-2015-0016 . OpenUrl
• ↵  Committee on Science Learning. Kindergarten through eighth grade. How children learn science. In: Duschl RA, Schweingruber A, Shouse AW, eds. Taking science to school: learning and teaching science in grades K-8. National Academies Press, 2007 .
• ↵ Vosniadou S. International handbook of research on conceptual change. 2nd ed . Routledge, 2013 .
• ↵ Abrami PC, Bernard RM, Borokhovski E, Waddington DI, Wade CA, Persson T. Strategies for teaching students to think critically a meta-analysis. Rev Educ Res 2015 ; 357 : 275 - 314 . OpenUrl
• ↵ Ross D, Schipper S, Westbury C, et al. Examining critical thinking skills in family medicine residents . Fam Med 2016 ; 357 : 121 - 6 . pmid:26950783 . OpenUrl
• ↵ Ross D, Loeffler K, Schipper S, Vandermeer B, Allan GM. Do scores on three commonly used measures of critical thinking correlate with academic success of health professions trainees? A systematic review and meta-analysis. Acad Med 2013 ; 357 : 724 - 34 . doi:10.1097/ACM.0b013e31828b0823   pmid:23524925 . OpenUrl
• ↵ Young T, Rohwer A, Volmink J, Clarke M. What are the effects of teaching evidence-based health care (EBHC)? Overview of systematic reviews. PLoS One 2014 ; 357 : e86706 . doi:10.1371/journal.pone.0086706   pmid:24489771 . OpenUrl
• ↵ Informed Health Choices Group. Informed health choices. www.informedhealthchoices.org
• ↵ Harden RM, Stamper N. What is a spiral curriculum? Med Teach 1999 ; 357 : 141 - 3 . doi:10.1080/01421599979752   pmid:21275727 . OpenUrl
• ↵ Austvoll-Dahlgren A, Oxman AD, Chalmers I, et al. Key concepts that people need to understand to assess claims about treatment effects. J Evid Based Med 2015 ; 357 : 112 - 25 . doi:10.1111/jebm.12160   pmid:26107552 . OpenUrl
• ↵ Austvoll-Dahlgren A, Nsangi A, Semakula D. Interventions and assessment tools addressing key concepts people need to know to appraise claims about treatment effects: a systematic mapping review. Syst Rev 2016 ; 357 : 215 . doi:10.1186/s13643-016-0389-z   pmid:28034307 . OpenUrl
• ↵ Austvoll-Dahlgren A, Semakula D, Nsangi A, et al. The development of the “claim evaluation tools”: assessing critical thinking about effects. BMJ Open forthcoming .
• ↵ Austvoll-Dahlgren A, Guttersrud Ø, Semakula D, Nsangi A, Oxman AD. Measuring ability to assess claims about treatment effects: a latent trait analysis of the claim evaluation tools using Rasch modelling. BMJ Open [ forthcoming ].
• ↵ Sandoval WA, Sodian B, Koerber S, Wong J. Developing children’s early competencies to engage with science . Educ Psychol 2014 ; 357 : 139 - 52 doi:10.1080/00461520.2014.917589 . OpenUrl
• ↵ Pintrich PR. A motivational science perspective on the role of student motivation in learning and teaching contexts . J Educ Psychol 2003 ; 357 : 667 - 86 doi:10.1037/0022-0663.95.4.667 . OpenUrl
• ↵ Clark DB, Tanner-Smith EE, Killingsworth SS. Digital games, design, and learning: a systematic review and meta-analysis . Rev Educ Res 2016 ; 357 : 79 - 122 . doi:10.3102/0034654315582065   pmid:26937054 . OpenUrl
• ↵ Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review . Ann Intern Med 2011 ; 357 : 97 - 107 . doi:10.7326/0003-4819-155-2-201107190-00005   pmid:21768583 . OpenUrl
• ↵ Lundh A, Sismondo S, Lexchin J, Busuioc OA, Bero L. Industry sponsorship and research outcome. Cochrane Database Syst Rev 2012 ; 357 : MR000033 . pmid:23235689 . OpenUrl
• ↵ Thistlethwaite J, Hammick M, The Best Evidence Medical Education (BEME) Collaboration: into the next decade. Med Teach 2010 ; 357 : 880 - 2 . doi:10.3109/0142159X.2010.519068   pmid:21039096 . OpenUrl
• ↵ Centre for Evidence Based Medicine. Einstein—taking EBM to schools. http://www.cebm.net/taking-ebm-schools
• ↵ Castle JC, Chalmers I, Atkinson P, et al. Establishing a library of resources to help people understand key concepts in assessing treatment claims—the Critical Thinking and Appraisal Resource Library (CARL). PLoS One forthcoming .

The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

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Developing critical thinking skills for delivering optimal care

Scott IA, Hubbard RE, Crock C, et al. Developing critical thinking skills for delivering optimal care. Intern Med J. 2021;51(4):488-493. doi: 10.1111/imj.15272

Sound critical thinking skills can help clinicians avoid cognitive biases and diagnostic errors. This article describes three critical thinking skills essential to effective clinical care – clinical reasoning, evidence-informed decision-making, and systems thinking – and approaches to develop these skills during clinician training.

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Cultivating Critical Thinking in Healthcare

Published: 06 January 2019

Critical thinking skills have been linked to improved patient outcomes, better quality patient care and improved safety outcomes in healthcare (Jacob et al. 2017).

Given this, it's necessary for educators in healthcare to stimulate and lead further dialogue about how these skills are taught , assessed and integrated into the design and development of staff and nurse education and training programs (Papp et al. 2014).

So, what exactly is critical thinking and how can healthcare educators cultivate it amongst their staff?

What is Critical Thinking?

In general terms, ‘ critical thinking ’ is often used, and perhaps confused, with problem-solving and clinical decision-making skills .

In practice, however, problem-solving tends to focus on the identification and resolution of a problem, whilst critical thinking goes beyond this to incorporate asking skilled questions and critiquing solutions .

Several formal definitions of critical thinking can be found in literature, but in the view of Kahlke and Eva (2018), most of these definitions have limitations. That said, Papp et al. (2014) offer a useful starting point, suggesting that critical thinking is:

‘The ability to apply higher order cognitive skills and the disposition to be deliberate about thinking that leads to action that is logical and appropriate.’

The Foundation for Critical Thinking (2017) expands on this and suggests that:

‘Critical thinking is that mode of thinking, about any subject, content, or problem, in which the thinker improves the quality of his or her thinking by skillfully analysing, assessing, and reconstructing it.’

They go on to suggest that critical thinking is:

• Self-directed
• Self-disciplined
• Self-monitored
• Self-corrective.

Key Qualities and Characteristics of a Critical Thinker

Given that critical thinking is a process that encompasses conceptualisation , application , analysis , synthesis , evaluation and reflection , what qualities should be expected from a critical thinker?

In answering this question, Fortepiani (2018) suggests that critical thinkers should be able to:

• Formulate clear and precise questions
• Gather, assess and interpret relevant information
• Reach relevant well-reasoned conclusions and solutions
• Think open-mindedly, recognising their own assumptions
• Communicate effectively with others on solutions to complex problems.

All of these qualities are important, however, good communication skills are generally considered to be the bedrock of critical thinking. Why? Because they help to create a dialogue that invites questions, reflections and an open-minded approach, as well as generating a positive learning environment needed to support all forms of communication.

Lippincott Solutions (2018) outlines a broad spectrum of characteristics attributed to strong critical thinkers. They include:

• Inquisitiveness with regard to a wide range of issues
• A concern to become and remain well-informed
• Alertness to opportunities to use critical thinking
• Self-confidence in one’s own abilities to reason
• Open mindedness regarding divergent world views
• Flexibility in considering alternatives and opinions
• Understanding the opinions of other people
• Fair-mindedness in appraising reasoning
• Honesty in facing one’s own biases, prejudices, stereotypes or egocentric tendencies
• A willingness to reconsider and revise views where honest reflection suggests that change is warranted.

Papp et al. (2014) also helpfully suggest that the following five milestones can be used as a guide to help develop competency in critical thinking:

Stage 1: Unreflective Thinker

At this stage, the unreflective thinker can’t examine their own actions and cognitive processes and is unaware of different approaches to thinking.

Stage 2: Beginning Critical Thinker

Here, the learner begins to think critically and starts to recognise cognitive differences in other people. However, external motivation  is needed to sustain reflection on the learners’ own thought processes.

Stage 3: Practicing Critical Thinker

By now, the learner is familiar with their own thinking processes and makes a conscious effort to practice critical thinking.

Stage 4: Advanced Critical Thinker

As an advanced critical thinker, the learner is able to identify different cognitive processes and consciously uses critical thinking skills.

Stage 5: Accomplished Critical Thinker

At this stage, the skilled critical thinker can take charge of their thinking and habitually monitors, revises and rethinks approaches for continual improvement of their cognitive strategies.

Facilitating Critical Thinking in Healthcare

A common challenge for many educators and facilitators in healthcare is encouraging students to move away from passive learning towards active learning situations that require critical thinking skills.

Just as there are similarities among the definitions of critical thinking across subject areas and levels, there are also several generally recognised hallmarks of teaching for critical thinking . These include:

• Promoting interaction among students as they learn
• Asking open ended questions that do not assume one right answer
• Allowing sufficient time to reflect on the questions asked or problems posed
• Teaching for transfer - helping learners to see how a newly acquired skill can apply to other situations and experiences.

(Lippincott Solutions 2018)

Snyder and Snyder (2008) also make the point that it’s helpful for educators and facilitators to be aware of any initial resistance that learners may have and try to guide them through the process. They should aim to create a learning environment where learners can feel comfortable thinking through an answer rather than simply having an answer given to them.

Examples include using peer coaching techniques , mentoring or preceptorship to engage students in active learning and critical thinking skills, or integrating project-based learning activities that require students to apply their knowledge in a realistic healthcare environment.

Carvalhoa et al. (2017) also advocate problem-based learning as a widely used and successful way of stimulating critical thinking skills in the learner. This view is echoed by Tsui-Mei (2015), who notes that critical thinking, systematic analysis and curiosity significantly improve after practice-based learning .

Integrating Critical Thinking Skills Into Curriculum Design

Most educators agree that critical thinking can’t easily be developed if the program curriculum is not designed to support it. This means that a deep understanding of the nature and value of critical thinking skills needs to be present from the outset of the curriculum design process , and not just bolted on as an afterthought.

In the view of Fortepiani (2018), critical thinking skills can be summarised by the statement that 'thinking is driven by questions', which means that teaching materials need to be designed in such a way as to encourage students to expand their learning by asking questions that generate further questions and stimulate the thinking process. Ideal questions are those that:

• Embrace complexity
• Challenge assumptions and points of view
• Question the source of information
• Explore variable interpretations and potential implications of information.

To put it another way, asking questions with limiting, thought-stopping answers inhibits the development of critical thinking. This means that educators must ideally be critical thinkers themselves .

Drawing these threads together, The Foundation for Critical Thinking (2017) offers us a simple reminder that even though it’s human nature to be ‘thinking’ most of the time, most thoughts, if not guided and structured, tend to be biased, distorted, partial, uninformed or even prejudiced.

They also note that the quality of work depends precisely on the quality of the practitioners’ thought processes. Given that practitioners are being asked to meet the challenge of ever more complex care, the importance of cultivating critical thinking skills, alongside advanced problem-solving skills , seems to be taking on new importance.

Additional Resources

• The Emotionally Intelligent Nurse | Ausmed Article
• Refining Competency-Based Assessment | Ausmed Article
• Socratic Questioning in Healthcare | Ausmed Article
• Carvalhoa, D P S R P et al. 2017, 'Strategies Used for the Promotion of Critical Thinking in Nursing Undergraduate Education: A Systematic Review', Nurse Education Today , vol. 57, pp. 103-10, viewed 7 December 2018, https://www.sciencedirect.com/science/article/abs/pii/S0260691717301715
• Fortepiani, L A 2017, 'Critical Thinking or Traditional Teaching For Health Professionals', PECOP Blog , 16 January, viewed 7 December 2018, https://blog.lifescitrc.org/pecop/2017/01/16/critical-thinking-or-traditional-teaching-for-health-professions/
• Jacob, E, Duffield, C & Jacob, D 2017, 'A Protocol For the Development of a Critical Thinking Assessment Tool for Nurses Using a Delphi Technique', Journal of Advanced Nursing, vol. 73, no. 8, pp. 1982-1988, viewed 7 December 2018, https://onlinelibrary.wiley.com/doi/10.1111/jan.13306
• Kahlke, R & Eva, K 2018, 'Constructing Critical Thinking in Health Professional Education', Perspectives on Medical Education , vol. 7, no. 3, pp. 156-165, viewed 7 December 2018, https://link.springer.com/article/10.1007/s40037-018-0415-z
• Lippincott Solutions 2018, 'Turning New Nurses Into Critical Thinkers', Lippincott Solutions , viewed 10 December 2018, https://www.wolterskluwer.com/en/expert-insights/turning-new-nurses-into-critical-thinkers
• Papp, K K 2014, 'Milestones of Critical Thinking: A Developmental Model for Medicine and Nursing', Academic Medicine , vol. 89, no. 5, pp. 715-720, https://journals.lww.com/academicmedicine/Fulltext/2014/05000/Milestones_of_Critical_Thinking___A_Developmental.14.aspx
• Snyder, L G & Snyder, M J 2008, 'Teaching Critical Thinking and Problem Solving Skills', The Delta Pi Epsilon Journal , vol. L, no. 2, pp. 90-99, viewed 7 December 2018, https://dme.childrenshospital.org/wp-content/uploads/2019/02/Optional-_Teaching-Critical-Thinking-and-Problem-Solving-Skills.pdf
• The Foundation for Critical Thinking 2017, Defining Critical Thinking , The Foundation for Critical Thinking, viewed 7 December 2018, https://www.criticalthinking.org/pages/our-conception-of-critical-thinking/411
• Tsui-Mei, H, Lee-Chun, H & Chen-Ju MSN, K 2015, 'How Mental Health Nurses Improve Their Critical Thinking Through Problem-Based Learning', Journal for Nurses in Professional Development , vol. 31, no. 3, pp. 170-175, viewed 7 December 2018, https://journals.lww.com/jnsdonline/Abstract/2015/05000/How_Mental_Health_Nurses_Improve_Their_Critical.8.aspx

Anne Watkins View profile

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Critical Thinking in Critical Care: Five Strategies to Improve Teaching and Learning in the Intensive Care Unit

Affiliations.

• 1 1 Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
• 2 2 Shapiro Institute for Education and Research at Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; and.
• 3 3 Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Massachusetts.
• PMID: 28157389
• PMCID: PMC5461985
• DOI: 10.1513/AnnalsATS.201612-1009AS

Critical thinking, the capacity to be deliberate about thinking, is increasingly the focus of undergraduate medical education, but is not commonly addressed in graduate medical education. Without critical thinking, physicians, and particularly residents, are prone to cognitive errors, which can lead to diagnostic errors, especially in a high-stakes environment such as the intensive care unit. Although challenging, critical thinking skills can be taught. At this time, there is a paucity of data to support an educational gold standard for teaching critical thinking, but we believe that five strategies, routed in cognitive theory and our personal teaching experiences, provide an effective framework to teach critical thinking in the intensive care unit. The five strategies are: make the thinking process explicit by helping learners understand that the brain uses two cognitive processes: type 1, an intuitive pattern-recognizing process, and type 2, an analytic process; discuss cognitive biases, such as premature closure, and teach residents to minimize biases by expressing uncertainty and keeping differentials broad; model and teach inductive reasoning by utilizing concept and mechanism maps and explicitly teach how this reasoning differs from the more commonly used hypothetico-deductive reasoning; use questions to stimulate critical thinking: "how" or "why" questions can be used to coach trainees and to uncover their thought processes; and assess and provide feedback on learner's critical thinking. We believe these five strategies provide practical approaches for teaching critical thinking in the intensive care unit.

Keywords: cognitive errors; critical care; critical thinking; medical education.

• Clinical Competence*
• Critical Care*
• Education, Medical, Graduate / methods*
• Intensive Care Units
• Quality Improvement

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Critical Thinking: The Development of an Essential Skill for Nursing Students

Ioanna v. papathanasiou.

1 Nursing Department, Technological Educational Institute of Thessaly, Greece

Christos F. Kleisiaris

2 Nursing Department, Technological Educational Institute of Crete, Greece

Evangelos C. Fradelos

3 State Mental Hospital of Attica “Daphne”, Greece

Katerina Kakou

Lambrini kourkouta.

4 Nursing Department, Alexander Technological Educational Institute of Thessaloniki, Greece

Critical thinking is defined as the mental process of actively and skillfully perception, analysis, synthesis and evaluation of collected information through observation, experience and communication that leads to a decision for action. In nursing education there is frequent reference to critical thinking and to the significance that it has in daily clinical nursing practice. Nursing clinical instructors know that students face difficulties in making decisions related to clinical practice. The main critical thinking skills in which nursing students should be exercised during their studies are critical analysis, introductory and concluding justification, valid conclusion, distinguish of facts and opinions, evaluation the credibility of information sources, clarification of concepts and recognition of conditions. Specific behaviors are essentials for enhancing critical thinking. Nursing students in order to learn and apply critical thinking should develop independence of thought, fairness, perspicacity in personal and social level, humility, spiritual courage, integrity, perseverance, self-confidence, interest for research and curiosity. Critical thinking is an essential process for the safe, efficient and skillful nursing practice. The nursing education programs should adopt attitudes that promote critical thinking and mobilize the skills of critical reasoning.

1. INTRODUCTION

Critical thinking is applied by nurses in the process of solving problems of patients and decision-making process with creativity to enhance the effect. It is an essential process for a safe, efficient and skillful nursing intervention. Critical thinking according to Scriven and Paul is the mental active process and subtle perception, analysis, synthesis and evaluation of information collected or derived from observation, experience, reflection, reasoning or the communication leading to conviction for action ( 1 ).

So, nurses must adopt positions that promote critical thinking and refine skills of critical reasoning in order a meaningful assessment of both the previous and the new information and decisions taken daily on hospitalization and use of limited resources, forces you to think and act in cases where there are neither clear answers nor specific procedures and where opposing forces transform decision making in a complex process ( 2 ).

Critical thinking applies to nurses as they have diverse multifaceted knowledge to handle the various situations encountered during their shifts still face constant changes in an environment with constant stress of changing conditions and make important decisions using critical thinking to collect and interpret information that are necessary for making a decision ( 3 ).

Critical thinking, combined with creativity, refine the result as nurses can find specific solutions to specific problems with creativity taking place where traditional interventions are not effective. Even with creativity, nurses generate new ideas quickly, get flexible and natural, create original solutions to problems, act independently and with confidence, even under pressure, and demonstrate originality ( 4 ).

The aim of the study is to present the basic skills of critical thinking, to highlight critical thinking as a essential skill for nursing education and a fundamental skill for decision making in nursing practice. Moreover to indicate the positive effect and relation that critical thinking has on professional outcomes.

2. CRITICAL THINKING SKILLS

Nurses in their efforts to implement critical thinking should develop some methods as well as cognitive skills required in analysis, problem solving and decision making ( 5 ). These skills include critical analysis, introductory and concluding justification, valid conclusion, distinguishing facts and opinions to assess the credibility of sources of information, clarification of concepts, and recognition conditions ( 6 , 7 ).

Critical analysis is applied to a set of questions that relate to the event or concept for the determination of important information and ideas and discarding the unnecessary ones. It is, thus, a set of criteria to rationalize an idea where one must know all the questions but to use the appropriate one in this case ( 8 ).

The Socratic Method, where the question and the answer are sought, is a technique in which one can investigate below the surface, recognize and examine the condition, look for the consequences, investigate the multiple data views and distinguish between what one knows and what he simply believes. This method should be implemented by nurses at the end of their shifts, when reviewing patient history and progress, planning the nursing plan or discussing the treatment of a patient with colleagues ( 9 ).

The Inference and Concluding justification are two other critical thinking skills, where the justification for inductive generalizations formed from a set of data and observations, which when considered together, specific pieces of information constitute a special interpretation ( 10 ). In contrast, the justification is deduced from the general to the specific. According to this, nurse starts from a conceptual framework–for example, the prioritization of needs by Maslow or a context–evident and gives descriptive interpretation of the patient’s condition with respect to this framework. So, the nurse who uses drawing needs categorizes information and defines the problem of the patient based on eradication, nutrition or need protection.

In critical thinking, the nurses still distinguish claims based on facts, conclusions, judgments and opinions. The assessment of the reliability of information is an important stage of critical thinking, where the nurse needs to confirm the accuracy of this information by checking other evidence and informants ( 10 ).

The concepts are ideas and opinions that represent objects in the real world and the importance of them. Each person has developed its own concepts, where they are nested by others, either based on personal experience or study or other activities. For a clear understanding of the situation of the patient, the nurse and the patient should be in agreement with the importance of concepts.

People also live under certain assumptions. Many believe that people generally have a generous nature, while others believe that it is a human tendency to act in its own interest. The nurse must believe that life should be considered as invaluable regardless of the condition of the patient, with the patient often believing that quality of life is more important than duration. Nurse and patient, realizing that they can make choices based on these assumptions, can work together for a common acceptable nursing plan ( 11 ).

3. CRITICAL THINKING ENHANCEMENT BEHAVIORS

The person applying critical thinking works to develop the following attitudes and characteristics independence of thought, fairness, insight into the personal and public level, humble intellect and postpone the crisis, spiritual courage, integrity, perseverance, self-confidence, research interest considerations not only behind the feelings and emotions but also behind the thoughts and curiosity ( 12 ).

Independence of Thought

Individuals who apply critical thinking as they mature acquire knowledge and experiences and examine their beliefs under new evidence. The nurses do not remain to what they were taught in school, but are “open-minded” in terms of different intervention methods technical skills.

Impartiality

Those who apply critical thinking are independent in different ways, based on evidence and not panic or personal and group biases. The nurse takes into account the views of both the younger and older family members.

Perspicacity into Personal and Social Factors

Those who are using critical thinking and accept the possibility that their personal prejudices, social pressures and habits could affect their judgment greatly. So, they try to actively interpret their prejudices whenever they think and decide.

Humble Cerebration and Deferral Crisis

Humble intellect means to have someone aware of the limits of his own knowledge. So, those who apply critical thinking are willing to admit they do not know something and believe that what we all consider rectum cannot always be true, because new evidence may emerge.

Spiritual Courage

The values and beliefs are not always obtained by rationality, meaning opinions that have been researched and proven that are supported by reasons and information. The courage should be true to their new ground in situations where social penalties for incompatibility are strict. In many cases the nurses who supported an attitude according to which if investigations are proved wrong, they are canceled.

Use of critical thinking to mentally intact individuals question their knowledge and beliefs quickly and thoroughly and cause the knowledge of others so that they are willing to admit and appreciate inconsistencies of both their own beliefs and the beliefs of the others.

Perseverance

The perseverance shown by nurses in exploring effective solutions for patient problems and nursing each determination helps to clarify concepts and to distinguish related issues despite the difficulties and failures. Using critical thinking they resist the temptation to find a quick and simple answer to avoid uncomfortable situations such as confusion and frustration.

Confidence in the Justification

According to critical thinking through well motivated reasoning leads to reliable conclusions. Using critical thinking nurses develop both the inductive and the deductive reasoning. The nurse gaining more experience of mental process and improvement, does not hesitate to disagree and be troubled thereby acting as a role model to colleagues, inspiring them to develop critical thinking.

Interesting Thoughts and Feelings for Research

Nurses need to recognize, examine and inspect or modify the emotions involved with critical thinking. So, if they feel anger, guilt and frustration for some event in their work, they should follow some steps: To restrict the operations for a while to avoid hasty conclusions and impulsive decisions, discuss negative feelings with a trusted, consume some of the energy produced by emotion, for example, doing calisthenics or walking, ponder over the situation and determine whether the emotional response is appropriate. After intense feelings abate, the nurse will be able to proceed objectively to necessary conclusions and to take the necessary decisions.

The internal debate, that has constantly in mind that the use of critical thinking is full of questions. So, a research nurse calculates traditions but does not hesitate to challenge them if you do not confirm their validity and reliability.

4. IMPLEMENTATION OF CRITICAL THINKING IN NURSING PRACTICE

In their shifts nurses act effectively without using critical thinking as many decisions are mainly based on habit and have a minimum reflection. Thus, higher critical thinking skills are put into operation, when some new ideas or needs are displayed to take a decision beyond routine. The nursing process is a systematic, rational method of planning and providing specialized nursing ( 13 ). The steps of the nursing process are assessment, diagnosis, planning, implementation, evaluation. The health care is setting the priorities of the day to apply critical thinking ( 14 ). Each nurse seeks awareness of reasoning as he/she applies the criteria and considerations and as thinking evolves ( 15 ).

Problem Solving

Problem solving helps to acquire knowledge as nurse obtains information explaining the nature of the problem and recommends possible solutions which evaluate and select the application of the best without rejecting them in a possible appeal of the original. Also, it approaches issues when solving problems that are often used is the empirical method, intuition, research process and the scientific method modified ( 16 ).

Experiential Method

This method is mainly used in home care nursing interventions where they cannot function properly because of the tools and equipment that are incomplete ( 17 ).

Intuition is the perception and understanding of concepts without the conscious use of reasoning. As a problem solving approach, as it is considered by many, is a form of guessing and therefore is characterized as an inappropriate basis for nursing decisions. But others see it as important and legitimate aspect of the crisis gained through knowledge and experience. The clinical experience allows the practitioner to recognize items and standards and approach the right conclusions. Many nurses are sensing the evolution of the patient’s condition which helps them to act sooner although the limited information. Despite the fact that the intuitive method of solving problems is recognized as part of nursing practice, it is not recommended for beginners or students because the cognitive level and the clinical experience is incomplete and does not allow a valid decision ( 16 ).

Research Process / Scientifically Modified Method

The research method is a worded, rational and systematic approach to problem solving. Health professionals working in uncontrolled situations need to implement a modified approach of the scientific method of problem solving. With critical thinking being important in all processes of problem solving, the nurse considers all possible solutions and decides on the choice of the most appropriate solution for each case ( 18 ).

The Decision

The decision is the selection of appropriate actions to fulfill the desired objective through critical thinking. Decisions should be taken when several exclusive options are available or when there is a choice of action or not. The nurse when facing multiple needs of patients, should set priorities and decide the order in which they help their patients. They should therefore: a) examine the advantages and disadvantages of each option, b) implement prioritization needs by Maslow, c) assess what actions can be delegated to others, and d) use any framework implementation priorities. Even nurses make decisions about their personal and professional lives. The successive stages of decision making are the Recognition of Objective or Purpose, Definition of criteria, Calculation Criteria, Exploration of Alternative Solutions, Consideration of Alternative Solutions, Design, Implementation, Evaluation result ( 16 ).

The contribution of critical thinking in decision making

Acquiring critical thinking and opinion is a question of practice. Critical thinking is not a phenomenon and we should all try to achieve some level of critical thinking to solve problems and make decisions successfully ( 19 - 21 ).

It is vital that the alteration of growing research or application of the Socratic Method or other technique since nurses revise the evaluation criteria of thinking and apply their own reasoning. So when they have knowledge of their own reasoning-as they apply critical thinking-they can detect syllogistic errors ( 22 – 26 ).

5. CONCLUSION

In responsible positions nurses should be especially aware of the climate of thought that is implemented and actively create an environment that stimulates and encourages diversity of opinion and research ideas ( 27 ). The nurses will also be applied to investigate the views of people from different cultures, religions, social and economic levels, family structures and different ages. Managing nurses should encourage colleagues to scrutinize the data prior to draw conclusions and to avoid “group thinking” which tends to vary without thinking of the will of the group. Critical thinking is an essential process for the safe, efficient and skillful nursing practice. The nursing education programs should adopt attitudes that promote critical thinking and mobilize the skills of critical reasoning.

CONFLICT OF INTEREST: NONE DECLARED.

Thinking Critically About the Quality of Critical Thinking Definitions and Measures

• First Online: 20 April 2016

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• Lily Fountain 4  

Part of the book series: Innovation and Change in Professional Education ((ICPE,volume 13))

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Leading policy and professional organizations are in agreement that critical thinking is a key competency for health professionals to function in our complex health care environment. There is far less clarity in professions education literature about what it really means or how to best measure it in providers and students. Therefore, in order to clarify terminology and describe the context, definitions, and measures in critical thinking research, a systematic review using the keywords “critical thinking” or the associated term “clinical reasoning,” cross keywords nurse and physician, resulting in 43 studies is presented in this chapter. Results indicated that an explicit definition was not provided in 43 % of the studies, 70 % ascribed equivalency to the terms critical thinking, clinical reasoning, clinical judgment, problem-solving, or decision-making, and 40 % used researcher-made study-specific measures. Full alignment of definition and measure was found in 47 % of studies, 42 % of studies reported validity for obtained scores, and reliability was documented in 54 % of studies. Keyword analysis identified six common constructs in nursing studies of critical thinking in nursing: individual interest, knowledge, relational reasoning, prioritization, inference, and evaluation, along with three contextual factors: patient assessment, caring, and environmental resource assessment. Recommendations for future research include increased use of purposeful samples spanning multiple levels of provider experience; documentation of effect sizes, means, SD, and n; adherence to official standards for reliability and validity requiring documentation of both previous and current datasets as appropriate; and greater use of factor analysis to validate scales or regression to test models. Finally, critical thinking research needs to use explicit definitions that are part and parcel of the measures that operationalize the construct, and alternative measures need to be developed that line up the attributes of the definition with the attributes measured in the instrument. Once we can accurately describe and measure critical thinking, we can better ensure that rising members of the professions can apply this vital competency to patient care.

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Abrami, P. C., Bernard, R. M., Borokhovski, E., Wade, A., Surkes, M. A., Tamim, R., & Zhang, D. (2008). Instructional interventions affecting critical thinking skills and dispositions: A stage 1 meta-analysis. Review of Educational Research, 78 , 1102–1134. doi: 10.3102/0034654308326084

Article   Google Scholar  

Ajjawi, R., & Higgs, J. (2008). Learning to reason: A journey of professional socialization. Advances in Health Sciences Education, 13 , 133–150. doi: 10.1007/s10459-006-9032-4

Alexander, P. A., & Murphy, P. K. (2000). The research base for APA’s learner-centered psychological principles. In N. Lambert & B. McCombs (Eds.), How students learn (pp. 25–60). Washington, DC: American Psychological Association.

Google Scholar  

American Association of Colleges of Nursing. (2008). Essentials of baccalaureate education for professional nursing practice . Washington, DC: American Association of Colleges of Nursing.

American Educational Research Association, American Psychological Association, National Council on Measurement in Education. (1999). Standards for educational and psychological testing . Washington, DC: American Educational Research Association.

American Educational Research Association, American Psychological Association, National Council on Measurement in Education. (2014). Standards for educational and psychological testing . Washington, DC: American Educational Research Association.

Bashir, M., Afzal, M. T., & Azeem, M. (2008). Reliability and validity of qualitative research. Pakistani Journal of Statistics and Operation Research, IV (1), 35–45.

Benner, P. E., Hughes, R. G., & Sutphen, M. (2008). Clinical reasoning, decision-making, and action: Thinking critically and clinically. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. AHRQ Publication No. 08-0043 . Rockville, MD: Agency for Healthcare Research and Quality.

Blondy, L. C. (2011). Measurement and comparison of nursing faculty members’ critical thinking skills. Western Journal of Nursing Research, 33 , 180–195. doi: 10.1177/0193945910381596

Brunt, B. A. (2005). Critical thinking in nursing: An integrated review. Journal of Continuing Education in Nursing, 36 , 60–67.

Carpenter, C. B., & Doig, J. C. (1988). Assessing critical thinking across the curriculum. New Directions for Teaching and Learning, 34 , 33–46. doi: 10.1002/tl.37219883405

Chan, Z. C. Y. (2013). A systematic review of critical thinking in nursing education. Nurse Education Today, 33 , 236–240.

Cook, D. A., & Beckman, T. J. (2006). Current concepts in validity and reliability for psychometric instruments: Theory and application. The American Journal of Medicine, 119 , 166.e7–166.e16.

Cooke, M., Irby, D. M., & O’Brien, B. C. (2010). Educating physicians: A call for reform of medical school and residency . San Francisco: Jossey-Bass.

Cooper, H., Hedges, L. V., & Valentine, J. C. (2009). The handbook of research synthesis and meta-analysis (2nd ed.). New York: Russell Sage Foundation.

Creswell, J. W. (1994). Research design: Qualitative and quantitative approaches . Thousand Oaks, CA: Sage Publications.

Creswell, J. W. (2014). Research design: Qualitative, quantitative, and mixed methods approaches . Thousand Oaks, CA: Sage Publications.

Crocker, L. M., & Algina, J. (2006). Introduction to classical and modern test theory . Mason, OH: Wadsworth Group/Thomas Learning.

Cruz, D. M., Pimenta, C. M., & Lunney, M. (2009). Improving critical thinking and clinical reasoning with a continuing education course. The Journal of Continuing Education in Nursing, 40 , 121–127. doi: 10.3928/00220124-20090301-05

Dinsmore, D. H., Alexander, P. A., & Loughlin, S. M. (2008). The impact of new learning environments in an engineering design course. Instructional Science, 36 , 375–393. doi: 10.1007/s11251-008-9061-x

Drennan, J. (2010). Critical thinking as an outcome of a master’s degree in nursing programme. Journal of Advanced Nursing, 66 , 422–431. doi: 10.1111/j.1365-2648.2009.05170.x

Ennis, R. H. (1989). Critical thinking and subject specificity: Clarification and needed research. Educational Researcher, 18 , 4–10. doi: 10.3102/0013189X018003004

Ennis, R. H. (1991). Critical thinking: A streamlined conception. Teaching Philosophy, 14 , 5–24.

Evidence for Policy and Practice Information (EPPI). (N.D.). Different types of review . Retrieved from http://eppi.ioe.ac.uk/cms/default.aspx?tabid=1915&language=en-US

Facione, P. A. (1990). Critical thinking: A statement of expert consensus for purposes of educational assessment and instruction . Millbrae, CA: The California Academic Press.

Forneris, S. G., & Peden-McAlpine, C. (2007). Evaluation of a reflective learning intervention to improve critical thinking in novice nurses. Journal of Advanced Nursing, 57 , 410–421. doi: 10.1111/j.1365-2648.2006.04120.x

Funkesson, K. H., Anbäckena, E.-M., & Ek, A.-C. (2007). Nurses’ reasoning process during care planning taking pressure ulcer prevention as an example: A think-aloud study. International Journal of Nursing Studies, 44 , 1109–1119. doi: 10.1016/j.ijnurstu.2006.04.016

Göransson, K. E., Ehnfors, M., Fonteyn, M. E., & Ehrenberg, A. (2007). Thinking strategies used by registered nurses during emergency department triage. Journal of Advanced Nursing, 61 , 163–172. doi: 10.1111/j.1365-2648.2007.04473.x

Harden, R. M., Grant, J., Buckley, G., & Hart, I. R. (2000). Best evidence medical education. Advances in Health Sciences Education, 5 , 71–90. doi: 10.1023/A:1009896431203

Higgs, J., & Jones, M. (Eds.). (2000). Clinical reasoning for health professionals . Boston: Butterworth Heinemann.

Huang, G. C., Newman, L. R., & Schwartzstein, R. M. (2014). Critical thinking in health professions education: Summary and consensus statements of the millennium conference 2011. Teaching and Learning in Medicine, 26 (1), 95–102.

Institute of Medicine. (2010). The future of nursing: Leading change, advancing health . Washington, D.C.: National Academies Press.

Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel . Washington, D.C.: Interprofessional Education Collaborative.

Johansson, M. E., Pilhammar, E., & Willman, A. (2009). Nurses’ clinical reasoning concerning management of peripheral venous cannulae. Journal of Clinical Nursing, 18 , 3366–3375. doi: 10.1111/j.1365-2702.2009.02973.x

Johnson, M. (2004). What’s wrong with nursing education research? Nurse Education Today, 24 , 585–588. doi: 10.1016/j.nedt.2004.09.005

Johnson, D., Flagg, A., & Dremsa, T. L. (2008). Effects of using human patient simulator (HPS™) versus a CD-ROM on cognition and critical thinking. Medical Education Online, 13 (1), 1–9. doi: 10.3885/meo.2008.T0000118

Kane, M. T. (1992). An argument-based approach to validity. Psychological Bulletin, 112 , 527–535. doi: 10.1037/0033-2909.112.3.527

Kataoka-Yahiro, M., & Saylor, C. (1994). A critical thinking model for nursing judgment. Journal of Nursing Education, 33 , 351–356.

Kimberlin, C. L., & Winterstein, A. G. (2008). Validity and reliability of measurement instruments used in research. American Journal of Health-System Pharmacy, 65 , 2276–2284.

Krupat, E., Sprague, J. M., Wolpaw, D., Haidet, P., Hatem, D., & O’Brien, B. (2011). Thinking critically about critical thinking: Ability, disposition or both? Medical Education, 45 (6), 625–635.

Kuiper, R. A., Heinrich, C., Matthias, A., Graham, M. J., & Bell-Kotwall, L. (2008). Debriefing with the OPT model of clinical reasoning during high fidelity patient simulation. International Journal of Nursing Education Scholarship, 5 (1), Article 17. doi: 10.2202/1548-923X.1466

Mamede, S., Schmidt, H. G., Rikers, R. M., Penaforte, J. C., & Coelho-Filho, J. M. (2007). Breaking down automaticity: Case ambiguity and the shift to reflective approaches in clinical reasoning. Medical Education, 41 , 1185–1192. doi: 10.1111/j.1365-2923.2007.02921.x

McAllister, M., Billett, S., Moyle, W., & Zimmer-Gembeck, M. (2009). Use of a think-aloud procedure to explore the relationship between clinical reasoning and solution-focused training in self-harm for emergency nurses. Journal of Psychiatric and Mental Health Nursing, 16 , 121–128. doi: 10.1111/j.1365-2850.2008.01339.x

McCartney, K., Burchinal, M. R., & Bub, K. L. (2006). Best practices in quantitative methods for developmentalists. Monographs of the Society for Research in Child Development, 71, 285. Chapter II, Measurement issues. doi: 10.1111/j.1540-5834.2006.00403.x

Nikopoulou-Smyrni, P., & Nikopoulos, C. K. (2007). A new integrated model of clinical reasoning: Development, description and preliminary assessment in patients with stroke. Disability and Rehabilitation, 29 , 1129–1138. doi: 10.1080/09638280600948318

Norman, G. (2005). Research in clinical reasoning: Past history and current trends. Medical Education, 39 , 418–427. doi: 10.1111/j.1365-2929.2005.02127.x

Ovretviet, J. (2011). BMJ Qual Saf 2011. 20 (Suppl1), i18ei23. doi: 10.1136/bmjqs.2010.045955

Patel, V. L., Arocha, J. F., & Zhang, J. (2004). Thinking and reasoning in medicine. In Keith Holyoak (Ed.), Cambridge handbook of thinking and reasoning . Cambridge, UK: Cambridge University Press.

Pintrich, P. R., Smith, D. A., Garcia, T., & McKeachie, W. J. (1991). A manual for the use of the Motivated Strategies for Learning Questionnaire (MSLQ) . Ann Arbor, MI: University of Michigan National Center for Research to Improve Postsecondary Teaching and Learning.

Ralston, P. A., & Bays, C. L. (2013). Enhancing critical thinking across the undergraduate experience: an exemplar from engineering. American Journal of Engineering Education (AJEE), 4 (2), 119–126.

Ratanawongsa, N., Thomas, P. A., Marinopoulos, S. S., Dorman, T., Wilson, L. M., Ashar, B. H., et al. (2008). The reported reliability and validity of methods for evaluating continuing medical education: A systematic review. Academic Medicine, 83 , 274–283. doi: 10.1097/ACM.0b013e3181637925

Rogers, J. C., & Holm, M. B. (1983). Clinical reasoning: The ethics, science, and art. American Journal of Occupational Therapy, 37 , 601–616. doi: 10.5014/ajot.37.9.601

Ross, D., Loeffler, K., Schipper, S., Vandermeer, B., & Allan, G. M. (2013). Do scores on three commonly used measures of critical thinking correlate with academic success of health professions trainees? A systematic review and meta-analysis. Academic Medicine, 88 (5), 724–734.

Schell, R., & Kaufman, D. (2009). Critical thinking in a collaborative online PBL tutorial. Journal of Educational Computing Research, 41 , 155–170. doi: 10.2190/EC.41.2.b

Simmons, B. (2010). Clinical reasoning: Concept analysis. Journal of Advanced Nursing, 66 , 1151–1158. doi: 10.1111/j.1365-2648.2010.05262.x

Simpson, E., & Courtney, M. D. (2002). Critical thinking in nursing education: A literature review. International Journal of Nursing Practice, 8 (April), 89–98. doi: 10.1046/j.1440-172x.2002.00340.x

Tanner, C. A. (1997). Spock would have been a terrible nurse and other issues related to critical thinking. Journal of Nursing Education, 36 , 3–4.

Turner, P. (2005). Critical thinking in nursing education and practice as defined in the literature. Nursing Education Perspectives, 26 , 272–277.

Walsh, C. M., & Seldomridge, L. A. (2006a). Critical thinking: Back to square two. Journal of Nursing Education, 45 , 212–219.

Walsh, C. M., & Seldomridge, L. A. (2006b). Measuring critical thinking: One step forward, one step back. Nurse Educator, 31 , 159–162.

Waltz, C. F. (2010). Measurement in nursing and health research (4th ed.). Philadelphia: Springer.

Watson, R., Stimpson, A., Topping, A., & Porock, D. (2002). Clinical competence assessment in nursing: A systematic review. Journal of Advanced Nursing, 39 , 421–431.

Wolpaw, T., Papp, K. K., & Bordage, G. (2009). Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: A randomized comparison group trial. Academic Medicine, 84 , 517–524. doi: 10.1097/ACM.0b013e31819a8cbf

Context (n. d.). In Merriam-Webster.com. Retrieved April 11, 2012 from http://www.merriam-webster.com/dictionary/context .

Alexander, P. A., Dinsmore, D. L., Fox, E., Grossnickle, E., Loughlin, S. M., Maggioni, L., Parkinson, M. M., & Winters, F. I. (2011). Higher order thinking and knowledge: Domain-general and domain-specific trends and future directions. In G. Shraw & D. H. Robinson (Eds.), Assessment of higher order thinking skills (pp. 47-88). Charlotte, NC: Information Age Publishing.

Fonteyn, M. E., & Cahill, M. (1998). The use of clinical logs to improve nursing students’ metacognition: A pilot study. Journal of Advanced Nursing, 28(1), 149-154.

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Fountain, L. (2016). Thinking Critically About the Quality of Critical Thinking Definitions and Measures. In: Wimmers, P., Mentkowski, M. (eds) Assessing Competence in Professional Performance across Disciplines and Professions. Innovation and Change in Professional Education, vol 13. Springer, Cham. https://doi.org/10.1007/978-3-319-30064-1_10

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